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Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Indicators Recommended for the Identification and Documentation of Pediatric Malnutrition (Undernutrition)

Published:November 24, 2014DOI:https://doi.org/10.1016/j.jand.2014.08.026

      Abstract

      The Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition, utilizing an evidence-informed, consensus-derived process, recommend that a standardized set of diagnostic indicators be used to identify and document pediatric malnutrition (undernutrition) in routine clinical practice. The recommended indicators include z scores for weight for height/length, body mass index for age, length/height for age, or mid-upper arm circumference when a single data point is available. When two or more data points are available, indicators may also include weight-gain velocity (younger than 2 years of age), weight loss (2 to 20 years of age), deceleration in weight for length/height z score, and inadequate nutrient intake. The purpose of this consensus statement is to identify a basic set of indicators that can be used to diagnose and document undernutrition in the pediatric population (ages 1 month to 18 years). The indicators are intended for use in multiple settings, such as acute, ambulatory care/outpatient, residential care, etc. Several screening tools have been developed for use in hospitalized children. However, identifying criteria for use in screening for nutritional risk is not the purpose of this paper. Clinicians should use as many data points as available to identify and document the presence of malnutrition. The universal use of a single set of diagnostic parameters will expedite the recognition of pediatric undernutrition, lead to the development of more accurate estimates of its prevalence and incidence, direct interventions, and promote improved outcomes. A standardized diagnostic approach will also inform the prediction of the human and financial responsibilities and costs associated with the prevention and treatment of undernutrition in this vulnerable population, and help to further ensure the provision of high-quality, cost-effective, nutrition care.
      Pediatric malnutrition (undernutrition) is estimated to contribute to approximately 45% of all child deaths globally.

      World Health Organization. 10 Facts on Child Health. Children: Reducing mortality. Fact sheet no. 178. Updated September 2013. http://www.who.int/mediacentre/factsheets/fs178/en/. Accessed May 5, 2014.

      Approximately 20 million children younger than 5 years of age worldwide are severely undernourished, leaving them extremely vulnerable to illness and premature death. Many older children in developing countries enter adolescence undernourished, which increases their vulnerability to disease and premature death.

      World Health Organization. Young people: Health risks and solutions. Fact sheet no. 345, August 2011. http://www.who.int/mediacentre/factsheets/fs345/en/index.html. Accessed May 5, 2014.

      Poverty, famine, and war are primary contributors to global malnutrition and limit food distribution and access, even when food is available for consumption. Development of acute or chronic infectious and/or diarrheal disease in those who are already undernourished contributes to the high mortality rates associated with pediatric malnutrition (undernutrition) in developing nations.
      • Grover Z.
      • Looi CEe
      Protein energy malnutrition.
      Pediatric undernutrition has historically been considered an issue exclusive to developing countries. Much of the groundbreaking research and initial development of malnutrition (undernutrition) criteria occurred with populations outside of the United States,
      • Schrimshaw N.
      • Viteri F.E.
      INCAP studies of kwashiorkor and marasmus.
      where acute or chronic infectious and/or diarrheal disease are major contributors to its development and to high rates of mortality. However, the clinical perspective and description of undernutrition has evolved during the past 3 decades. Unlike the undernutrition typically observed in developing countries, and usually categorized as marasmus and/or kwashiorkor, undernutrition in developed countries generally occurs in the setting of acute or chronic illness.
      • Grover Z.
      • Looi CEe
      Protein energy malnutrition.
      A number of US children suffer from energy imbalance and excess rather than nutrient deficiency. It is estimated that approximately 17% of US children and adolescents between 2 and 19 years of age are obese.
      • Ogden C.L.
      • Carroll M.D.
      • Kit B.K.
      • Flegal K.M.
      Prevalence of childhood and adult obesity in the United States, 2011-2012.
      Other data sets estimate that 1 in 10 US households with children struggle with food insecurity.
      • Coleman-Jensen A.
      • Nord M.
      • Singh A.
      Household Food Security in the United States in 2012.
      The current prevalence of US children who experience acute or chronic undernutrition is unknown. Children and adolescents who live in homeless shelters, are victims of abuse or neglect, or live in urban or rural areas where access to high-quality food is difficult, are thought to be at increased risk for undernutrition.
      Undernutrition in the United States is most frequently observed in hospitalized acute and/or chronically ill children, and in US children with special health care needs.
      • Grover Z.
      • Looi CEe
      Protein energy malnutrition.
      US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau
      The National Survey of Children with Special Health Care Needs Chartbook 2005-2006.
      Children with special needs are defined as “those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that of children generally.”
      US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau
      The National Survey of Children with Special Health Care Needs Chartbook 2005-2006.
      This definition encompasses children with nutrition-related chronic diseases or conditions, congenital anomalies, severe acute illness or injury, and those affected by abuse or neglect.
      Children and youth with special health care needs should be routinely screened for malnutrition in primary care settings. Registered dietitian nutritionists (RDNs), nurses, and all members of the health care team should collaborate to ensure that screening for malnutrition becomes an integral part of routine pediatric care. Although research is limited, malnutrition in this population can lead to more complicated hospitalizations due to progression of the underlying disease or condition, poor wound healing, or slow return to previous level of activity, complications that can significantly increase the length of stay and cost of hospitalization.
      • Hecht C.
      • Weber M.
      • Grote V.
      • et al.
      Disease associated malnutrition correlates with length of hospital stay in children.
      • Rodman M.
      • Mack R.
      • Barnoya J.
      • et al.
      The effect of preoperative nutritional status on postoperative outcomes in children undergoing surgery for congenital heart defects in San Francisco (UCSF) and Guatemala City (UNICAR).
      Comprehensive assessment and nutrition intervention in undernourished and malnourished children in primary care settings can reduce the need for more costly hospitalization by addressing nutritional deficits that can predispose the patient to acute illness or exacerbate the underlying disease or condition.
      • Geier L.M.
      • Bekx M.T.
      • Connor E.L.
      Factors contributing to initial weight loss among adolescents with polycystic ovary syndrome.
      Older studies suggest that up to 25% of all hospitalized children experienced acute protein-energy malnutrition, and approximately 27% experience chronic food insecurity.
      • Coleman-Jensen A.
      • Nord M.
      • Singh A.
      Household Food Security in the United States in 2012.
      • Hendricks K.M.
      • Duggan C.
      • Gallagher L.
      • et al.
      Malnutrition in hospitalized pediatric patients. Current prevalence.
      Inadequate intake, self-starvation, and/or purging behaviors associated with disordered eating/eating disorders can lead to malnutrition.
      • Sim L.A.
      • Lebow J.
      • Billings M.
      Eating disorders in adolescents with a history of obesity.
      These behaviors are most common among teenage girls. It is estimated that 0.5% of adolescents suffer with anorexia nervosa with another 1% to 2% meeting a diagnosis of bulimia nervosa. However, it is estimated that up to 14% of adolescents suffer from “partial syndromes or eating disorder not otherwise specified” and already have signs and symptoms of malnutrition.
      • Rosen D.S.
      American Academy of Pediatrics Committee on Adolescence. Identification and management of eating disorders in children and adolescents.
      Adolescents often try to hide aberrant eating behaviors. Laboratory parameters often remain normal for a period of time after aberrant eating behaviors have begun. The adolescent may already be in an undernourished state before presenting to a health care provider.
      • Sturdevant M.
      • Spear B.A.
      Eating disorders and obesity.
      In fact, the RDN may be the first provider to recognize the symptoms or the first provider contacted by the patient or caregivers.
      • Ozier A.D.
      • Henry B.W.
      American Dietetic Association. Position of the American Dietetic Association: Nutrition intervention in the treatment of eating disorders.

      Purpose

      The purpose of this consensus statement is to identify a basic set of indicators that can be used to diagnose and document undernutrition in the pediatric population ages 1 month to 18 years. The indicators are intended for use in multiple settings, such as acute, ambulatory care/outpatient, residential care, etc. Several screening tools have been developed for use in hospitalized children.
      • Joosten K.F.M.
      • Hulst J.M.
      Malnutrition in pediatric hospital patients: Current issues.
      However, identifying criteria for use in screening for nutritional risk is not the purpose of this paper. The diagnosis and documentation of undernutrition in neonates, recognition and documentation of micronutrient deficits in the pediatric population, and strategies to address micronutrient deficits are beyond the scope of this statement. Please refer to publications/resources specific to these topics for additional guidance.
      Academy of Nutrition and Dietetics
      Electronic Pediatric Nutrition Care Manual.
      Institute of Medicine, Food and Nutrition Board
      Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids.
      The diagnosis and treatment of pediatric obesity (overnutrition) are also not addressed in this statement.

      Definition of Pediatric Malnutrition (Undernutrition)

      The focus of this consensus statement is pediatric undernutrition. The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) has defined pediatric malnutrition (undernutrition) as “an imbalance between nutrient requirement and intake, resulting in cumulative deficits of energy, protein or micronutrients that may negatively affect growth, development and other relevant outcomes.”
      • Mehta N.M.
      • Corkins M.R.
      • Lyman B.
      • et al.
      Defining pediatric malnutrition: A paradigm shift towards etiology-related definitions.
      Pediatric undernutrition may be related to illness, adverse environmental or behavioral factors, injury, congenital anomalies, etc. The United Nations Children’s Fund (UNICEF) states that although malnutrition is a broad term commonly used as an alternative to undernutrition, it technically also encompasses overnutrition.
      World Health Organization and UNICEF
      WHO Child Growth Standards and the Identification of Severe Acute Malnutrition in Infants and Children: A Joint Statement by the World Health Organization and the United Nations Children's Fund.
      People are considered to be malnourished (undernourished) if their diet does not provide adequate energy and protein for growth and development, or if they are unable to fully utilize the food/nutrients due to illness. Children are also classified as malnourished (overnourished) if they consume too much energy. Although obesity is a form of malnutrition, a discussion of overnutrition is not the purpose this article.

      Acute vs Chronic Undernutrition

      Undernutrition is often characterized as acute or chronic. One way to distinguish between acute and chronic is time. Acute diseases or conditions are typically severe and sudden in onset. A chronic disease or condition tends to develop and become more severe over an extended period of time. The National Center for Health Statistics defines “chronic” as a disease or condition that has lasted for 3 months or longer.
      • Hagan J.C.
      Acute and chronic diseases.
      A chronic condition may contribute to an acute illness, just as an acute illness may evolve into a chronic condition, if unaddressed.
      The World Health Organization (WHO) and UNICEF have also provided guidance to distinguish between acute and chronic undernutrition by offering diagnostic parameters that help clinicians characterize the acuity level of undernutrition experienced by pediatric populations. Weight is primarily affected during periods of acute undernutrition, and chronic undernutrition typically manifests as stunting. Severe acute undernutrition, experienced by children ages 6 to 60 months of age, is defined as a very low weight for height (less than −3 standard deviations [SD]; z scores) of the median WHO growth standards), by visible severe wasting (a mid-upper arm circumference [MUAC] ≤115 mm), or by the presence of nutritional edema. Wasting is defined as a weight for age less than −2 SD (z score).

      World Health Organization. WHO 1995 Expert Committee Report: Physical status: The use and interpretation of anthropometry. Technical Report Series 854. Geneva, Switzerland: World Health Organization; 1995.

      World Health Organization
      WHO 1996 Catalogue Of Health Indicators: A Selection of Important Health Indicators Recommended by WHO Programmes.
      Chronic undernutrition or stunting is defined by WHO as having a height (or length) for age that is less than −2 SD (z score) of the median of the NCHS/WHO international reference.

      World Health Organization. WHO 1995 Expert Committee Report: Physical status: The use and interpretation of anthropometry. Technical Report Series 854. Geneva, Switzerland: World Health Organization; 1995.

      World Health Organization
      WHO 1996 Catalogue Of Health Indicators: A Selection of Important Health Indicators Recommended by WHO Programmes.
      An in-depth discussion of the z score is presented later in this paper.
      Stunting is a well-established indicator of chronic malnutrition, particularly undernutrition related to environmental or socioeconomic circumstances.

      World Health Organization. WHO 1995 Expert Committee Report: Physical status: The use and interpretation of anthropometry. Technical Report Series 854. Geneva, Switzerland: World Health Organization; 1995.

      World Health Organization
      WHO 1996 Catalogue Of Health Indicators: A Selection of Important Health Indicators Recommended by WHO Programmes.
      The height-for-age measurement represents the linear growth or stature actually achieved by the child at the age at which the child is measured. Height (ie, stature) is measured in the standing position. Length-for-age refers to measurements taken in the recumbent position and is recommended for children ≤2 years of age.

      World Health Organization. Prevalence of stunting in children ages 0-4 years. Geneva, Switzerland. www.who.int/entity/ceh/indicators/0_4stunting.pdf. Accessed May 5, 2014.

      Children in the age range of 0 to 4 years have the best potential outcomes from comprehensive assessment for malnutrition because timely intervention is highly likely to prevent adverse effects.

      World Health Organization. Prevalence of stunting in children ages 0-4 years. Geneva, Switzerland. www.who.int/entity/ceh/indicators/0_4stunting.pdf. Accessed May 5, 2014.

      Stunting may be observed during adolescence, which is also a period of rapid growth and development.
      The Figure lists examples of software programs that are available for individual z score calculation.

      World Health Organization. Determining SD or Z-scores for an individual using software. Lesson 3.2. Geneva, Switzerland. http://www.unicef.org/nutrition/training/3.2/24.html. Accessed May 5, 2014.

      Also, many growth charts (Fenton, WHO, Centers for Disease Control and Prevention [CDC]) are available on mobile technology applications and have made plotting very easy.
      FigureResources for determining z scores for anthropometrics.
      CDC
      CDC=Centers for Disease Control and Prevention.
      Growth Charts
      WHO
      WHO=World Health Organization.
      Growth Charts
      STAT GrowthCharts (compatible with iPod Touch, iPhone, iPad [Apple Inc])STAT GrowthCharts WHO (compatible with iPod Touch, iPhone, iPad [Apple Inc])
      Epi Info NutStat: (available for download)

      http://www.cdc.gov/growthcharts/computer_programs.htm
      WHO z score charts:

      http://www.who.int/childgrowth/standards/chart_catalogue/en/index.htm
      CDC website: z score data files available as tables:

      http://www.cdc.gov/growthcharts/zscore.htm
      WHO Multicentre Growth Study website:

      http://www.who.int/childgrowth/software/en/

      All four macros (SAS, S-plus, SSPS, and

      STATA) calculate the indicators of the attained growth standards
      PediTools Home: www.peditools.org

      Clinical tools for pediatric providers; growth charts, calculators, etc; mobile compatible
      PediTools Home: www.peditools.org

      Clinical tools for pediatric providers; growth charts, calculators, etc; mobile compatible
      a CDC=Centers for Disease Control and Prevention.
      b WHO=World Health Organization.

      Indicators of Pediatric Undernutrition

      A standardized approach to the recognition and diagnosis of pediatric undernutrition, particularly in the pediatric population older than 60 months, is lacking. Controversy surrounding the best and most useful approach(es) abound. Therefore, routine assessment of nutritional status in high-risk children in the United States is sporadic and inconsistent among facilities. A true measure of the impact of pediatric undernutrition on overall health is difficult to obtain. The US Survey of Children with Special Health Care Needs
      US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau
      The National Survey of Children with Special Health Care Needs Chartbook 2005-2006.
      does not currently include assessment of food/nutrition services provided; this data deficit must be addressed and the survey instrument revised to accommodate the collection of such data.

      Attributes of Indicators Selected for Inclusion

      A multitude of parameters have been developed for obtaining measurements in children in an effort to determine nutritional status. However, the increasing economic constraints of the US health care system mandate identification of the most reliable, reproducible, safe/low risk, and cost-effective indicators to support nutrition evaluation. Attributes of the indicators that we recommend are as follows:
      • are evidence-informed/consensus derived;
      • are universally available and validated;
      • can be applied inexpensively in multiple settings;
      • can be properly used with minimal training;
      • can reproducibly identify undernutrition;
      • can quantify severity of undernutrition; and
      • can be used to monitor changes in nutritional status.
      Indicators recommended to identify pediatric malnutrition are typically continuous rather than discrete variables. As such, clinical expertise and sound clinical judgment must be exercised when obtaining a history, completing the physical examination, developing differential diagnostic options, making a diagnosis, and implementing and monitoring a plan of care. Remember that the recommended list of indicators to be assessed may change over time, as evidence to support or to discontinue their use accrues, or as advances in assessment technology supplant their use.

      Consensus Recommendations

      We recommend that the following list of indicators be used when assessing and diagnosing pediatric malnutrition:

      Food/Nutrient Intake

      Food and nutrient intake are the primary determinants of nutritional status. Therefore, accurate assessment of intake and estimation of adequacy is critical. The primary concern is whether or not the child’s current intake is adequate to meet their nutrient needs in the context of their current clinical situation, growth pattern, and developmental level.
      • Mehta N.M.
      • Corkins M.R.
      • Lyman B.
      • et al.
      Defining pediatric malnutrition: A paradigm shift towards etiology-related definitions.
      Other diagnostic indicators are basically outcome measures of dietary adequacy.
      Estimates of the adequacy of protein/energy intake should be routinely determined for all children and especially in those identified as at increased risk for malnutrition. Accuracy in the estimation of adequacy of nutrient needs and assessment of the adequacy of food and nutrient intake are crucial to determining the magnitude of the deficit, as well as the extent and acuity of the deficit. Food/nutrient intake details can be obtained by history and/or by direct observation of food and/or nutrients consumed. Prescribed nutrition therapy intake should be monitored to ensure that the intended amounts are actually ingested by the child.

      Assessment of Energy and Protein Needs

      Energy needs can be measured by indirect calorimetry
      • Sion-Sarid R.
      • Cohen J.
      • Houri Z.
      • Singer P.
      Indirect calorimetry: A guide for optimizing nutritional support in the critically ill child.
      • Dokken M.
      • Rustøen T.
      • Stubhaug A.
      Indirect calorimetry reveals that better monitoring of nutrition therapy in pediatric intensive care is needed.
      or estimated through the use of standard equations.
      • Carney L.N.
      • Blair J.
      Assessment of nutritional status and determining nutrient needs.
      Each of the methods to estimate energy needs are just that, an estimation. Ideally, clinicians should perform indirect calorimetry to measure a child's actual energy requirements. Indirect calorimetry is the most precise method for the determination of energy expenditure because predictive equations do not accurately determine energy expenditure or account for the variability of a child’s metabolic state during the course of an illness.
      • Sion-Sarid R.
      • Cohen J.
      • Houri Z.
      • Singer P.
      Indirect calorimetry: A guide for optimizing nutritional support in the critically ill child.
      • Dokken M.
      • Rustøen T.
      • Stubhaug A.
      Indirect calorimetry reveals that better monitoring of nutrition therapy in pediatric intensive care is needed.
      The Food and Agriculture Organization/WHO
      World Health Organization
      Energy and Protein Requirements. Report of a Joint FAO/WHO/UNU Expert Consultation.
      and Schofield
      • Schofield W.N.
      Predicting basal metabolic rate, new standards and review of previous work.
      equations, although imprecise and developed to estimate the energy utilization of healthy children, are the most widely used formulas to estimate energy needs. These equations are frequently used when equipment for indirect calorimetry assessment is unavailable. Estimation of energy requirement can also be determined using the 1989 Recommended Dietary Allowance
      Committee on Dietary Allowances, Food and Nutrition Board, National Research Council
      Recommended Dietary Allowances.
      or the 2005 Dietary Reference Intake estimated energy requirements.
      Institute of Medicine, Food and Nutrition Board
      Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids.
      However, both of these methods also represent estimations of the energy needs of the “healthy” child.
      • Carney L.N.
      • Blair J.
      Assessment of nutritional status and determining nutrient needs.
      Predictive equations for determining energy requirements can be used initially and are summarized in Table 1.
      Table 1Estimating nutrient needs: A.S.P.E.N. 2010 Pediatric Nutrition Support Core Curriculum
      Adapted from Carney LN. Assessment of nutrition status by age and determining nutrient needs. In: Corkins MR, Balint J, Bobo E, Plogsted S, Yaworski JA, eds. The A.S.P.E.N. Pediatric Nutrition Support Core Curriculum. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition; 2010:418-419, with permission from the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).31 A.S.P.E.N. does not endorse the use of this material in any form other than its entirety.
      Name of equation or formula and sourceDescription and application to patient populationCalculations for the equation or formula
      Energy
      1989 Recommended Daily Allowance (RDA)

      Committee in Dietary Allowances, Food and Nutrition Board, National Research Council. Recommended Dietary Allowances. 10th ed. Washington, DC: National Academies Press; 1989.
      Based on the median energy intakes of children followed in longitudinal growth studies

      It can overestimate needs in nonactive populations (eg, bedridden) and does not provide a range of energy needs

      Although an outdated reference, still widely used

      Most often used for healthy infants and children
      Infants:

      0 to 0.5 y: 108×weight (kg)

      0.5 to 1 y: 98×weight

      Children:

      1 to 3 y: 102×weight

      4 to 6 y: 90×weight

      7 to 10 y: 70×weight

      Males:

      11 to 14 y: 55×weight

      15 to 18 y: 45×weight

      Females:

      11 to 14 y: 47×weight

      15 to 18 y: 40×weight
      Estimated energy requirements (EER) (new DRI/IOM
      DRI/IOM=Dietary Reference Intake/Institute of Medicine.
      equation) and physical activity (PA) coefficients

      National Academy of Sciences, Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients) (2005).
      Replaces the 1989 RDA

      Energy needs were determined from children with normal growth, body composition, and activity, and who are also metabolically normal

      Children with normal growth, body composition, and activity, and who are also metabolically normal

      Four categories of physical activity level (PAL)
      EER = total energy expenditure (TEE)+energy deposition

      Ages 0 to 36 mo:

      0 to 3 mo: (89×weight [kg]−100)+175

      4 to 6 mo: (89×weight [kg]−100)+56

      7 to 12 mo: (89×weight [kg]−100)+22

      13 to 36 mo: (89×weight [kg]−100)+20

      Ages 3 to 8 y boys:

      EER=88.5−(61.9×age [y])+PA×(26.7×weight [kg]+903×height [m])+20 kcal

      PA=1 if PAL is estimated to be >1 <1.4 (sedentary)

      PA=1.13 if PAL is estimated to be >1.4 <1.6 (low active)

      PA=1.26 if PAL is estimated to be >1.6 <1.9 (active)

      PA=1.42 if PAL is estimated to be >1.9 <2.5 (very active)

      Ages 3 to 8 y, girls:

      EER=135.3−(30.8×age [y])+PA×(10×weight [kg]+934×height [m])+20 kcal

      PA=1 if PAL is estimated to be >1 <1.4 (sedentary)

      PA=1.16 if PAL is estimated to be >1.4 <1.6 (low active)

      PA=1.31 if PAL is estimated to be >1.6 <1.9 (active)

      PA=1.56 if PAL is estimated to be >1.9 <2.5 (very active)

      Ages 9 to 18 y — Boys:

      EER=88.5−(61.9×age [y])+PA×(26.7×weight [kg]+903×height [m])+25 kcal

      PA=1 if PAL is estimated to be >1 <1.4 (sedentary)

      PA=1.13 if PAL is estimated to be >1.4 <1.6 (low active)

      PA=1.26 if PAL is estimated to be >1.6 <1.9 (active)

      PA=1.42 if PAL is estimated to be >1.9 <2.5 (very active)

      Ages 9 to 18 y — Girls:

      EER=135.3−(30.8×age [y])+PA×(10×weight [kg]+934×height [m])+25 kcal

      PA=1 if PAL is estimated to be >1 <1.4 (sedentary)

      PA=1.16 if PAL is estimated to be >1.4 <1.6 (low active)

      PA=1.31 if PAL is estimated to be >1.6 <1.9 (active)

      PA=1.56 if PAL is estimated to be >1.9 <2.5 (very active)
      EER (new DRI/IOM equation) and obesity coefficients/factors

      National Academy of Sciences, Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients) (2005).
      Overweight children who are metabolically normalWeight maintenance TEE in overweight boys Ages 3 to 18 y:

      TEE=114−(50.9×age [y])+PA×(19.5×weight [kg]+1,161.4 × height [m])

      PA=1 if PAL is estimated to be >1 <1.4 (sedentary)

      PA=1.12 if PAL is estimated to be >1.4 <1.6 (low active)

      PA=1.24 if PAL is estimated to be >1.6 <1.9 (active)

      PA=1.45 if PAL is estimated to be >1.9 <2.5 (very active)

      Weight maintenance TEE in overweight girls ages 3 to 18 y:

      TEE=389−(41.2×age [y])+PA×(15×weight [kg]+701.6×height [m])

      PA=1 if PAL is estimated to be >1 <1.4 (sedentary)

      PA=1.18 if PAL is estimated to be >1.4 <1.6 (low active)

      PA=1.35 if PAL is estimated to be >1.6 <1.9 (active)

      PA=1.6 if PAL is estimated to be >1.9 <2.5 (very active)
      Schofield WN. Predicting basal metabolism rate, new standards and review of previous work. Hum Nutr Clin Nutr. 1985;39(suppl 1):5-41.A predictive equation for calculating basal metabolic rate (BMR) in healthy children that was developed by analysis of Fritz Talbot tables

      Healthy children, acutely ill patients in the hospital setting
      Males:

      0 to 3 y: (0.167×weight [kg])+(15.174×height [cm])−617.6

      3 to 10 y: (19.59×weight [kg])+(1.303×height [cm])+414.9

      10 to 18 y: (16.25×weight [kg])+(1.372×height [cm])+515.5

      >18 y: (15.057×weight [kg])+(1.0004×height [cm])+705.8

      Females:

      0 to 3 y: (16.252×weight [kg])+(10.232×height [cm])−413.5

      3 to 10 y: (16.969×weight [kg])+(1.618×height [cm])+371.2

      10 to 18 y: (8.365×weight [kg])+(4.65×height [cm])+200

      >18 y: (13.623×weight [kg])+(23.8×height [cm])+98.2)
      FAO/WHO
      FAO/WHO=Food and Agricultural Organization of the United Nations/World Health Organization.


      World Health Organization. Energy and Protein Requirements. Report of a Joint FAO/WHO/UNU Expert Consultation. Technical Report Series 724. Geneva: World Health Organization; 1985.
      The “WHO equation” was developed for use in healthy children, however, it is commonly used to predict resting energy expenditure (REE) of acutely ill patients in the hospital settingMales:

      0 to 3 y: (60.9×weight [kg])−54

      3 to 10 y: (22.7×weight [kg])+495

      10 to 18 y: (17.5×weight [kg])+651

      Females:

      0 to 3 y: (61×weight [kg])−51

      3 to 10 y: (22.5×weight [kg])+499

      10 to 18 y: (12.2×weight [kg])+746
      Estimating calorie needs for developmental disabilities

      Rokusek C, Heindicles E. Nutrition and Feeding of the Developmentally Disabled. Brookings, SD: South Dakota University Affiliated Program, Interdisciplinary Center for Disabilities; 1985.
      Children with developmental disabilities (DD) may have a slower basal energy need due to decreased muscle tone, growth rate, and motor activity

      The recommendation to calculate energy needs in children with DD per cm of height is based on the fact that they tend to have a shorter height when compared to children with normal growth

      Children with DDs
      Cerebral palsy (age 5 to 11 y
      This reference applies to the specific ages listed. Please refer to another equation for ages outside of the referenced ages, and apply an appropriate activity/stress factor.
      ):

      Mild to moderate activity: 13.9 kcal/cm height

      Severe physical restrictions: 11.1 kcal/cm height

      Severe restricted activity: 10 kcal/cm height

      Athetoid cerebral palsy: Up to 6,000 kcal/day (adolescence)

      Down syndrome (5 to 12 y
      This reference applies to the specific ages listed. Please refer to another equation for ages outside of the referenced ages, and apply an appropriate activity/stress factor.
      ):

      Boys 16.1 kcal/cm height

      Girls 14.3 kcal/cm height

      Prader-Willi syndrome (for all children and adolescents):

      10 to 11 kcal/cm height for maintenance

      8.5 kcal/cm height for weight loss

      Myelomeningocele (spina bifida) (older than 8 y of age and minimally active):

      9 to 11 kcal/cm height for maintenance

      7 kcal/cm height for weight loss

      Approximately 50% RDA for age after infancy
      Peterson's Failure to Thrive

      Peterson KE, et al. Team management of failure-to-thrive. JADA. 1984;84(7):810-815.
      This calculates nutrients in excess of the requirements of the RDA

      Concerns with using this equation include refeeding syndrome

      Infants and children who present underweight and need to achieve catch-up growth
      [RDA for weight age (kcal/kg)×ideal body weight for height]÷actual weight
      FAO/WHO/UNU
      UNU=United Nations University.
      (aka “Dietz equation”)

      Dietz WH, Bandini LG, Schoeller DA. Estimates of metabolic rate in obese and non-obese adolescents. J Pediatr. 1991;118:146-149.
      Overweight/obese adolescents in an outpatient settingBoys 10 to 18 y BMR=16.6 weight (kg)+77 height (m)+572

      Girls 10 to 18 y BMR=7.4 weight (kg)+482 height (m)+217
      White equation

      White MS, Shepherd RW, McEniery JA. Energy expenditure in 100 ventilated, critically ill children: improving the accuracy of predictive equations. Crit Care Med. 2000;28(7):2307–2312.
      Developed for use in the pediatric critical care population by including temperature as a gauge of the body’s inflammatory response

      It is not commonly used in clinical practice, and recent studies have shown decreased accuracy especially in smaller, younger patients

      This equation should not be used in patients younger than 2 mo of age

      Pediatric critical care population
      EE (kJ/day)=(17×age [mo])+(48×weight [kg])+(292×body temperature [°C])−9,677
      Stress factors for energy
      Stress factors

      Leonberg B. ADA Pocket Guide to Pediatric Nutrition Assessment. Chicago, IL: American Dietetic Association; 2007. Table 8.10.
      The use of stress factors along with predictive energy equations should be considered for use in hospitalized children whose energy requirements may be altered due to metabolic stress

      Pediatric hospitalized population
      Starvation 0.70 to 0.85

      Surgery 1.05 to 1.5

      Sepsis 1.2 to 1.6

      Closed head injury 1.3

      Trauma 1.1 to 1.8

      Growth failure 1.5 to 2

      Burn 1.5 to 2.5
      Protein
      A.S.P.E.N. Clinical Guidelines: Nutrition Support of the Critically Ill Child

      Mehta NM, Compher C, ASPEN Board of Directors. A.S.P.E.N. Clinical Guidelines: Nutrition Support of the Critically Ill Child. JPEN J Parenter Enteral Nutr. 2009;33(3):260-276.
      Metabolic stress increases catabolism and breakdown of lean body mass

      To meet the increased demands of metabolic stress and spare the use of endogenous protein stores, a greater amount of protein is needed in this population until the underlying stress has been overcome

      Recommendations are based on limited data

      Pediatric critical care population
      0 to 2 y: 2 to 3 g/kg/day

      2 to 13 y: 1.5 to 2 g/kg/day

      13 to 18 y: 1.5 g/kg/day
      For the injured child

      Jaksic T. Effective and efficient nutritional support for the injured child. Surg Clin North Am. 2002;82(2):379-391, vii.
      Metabolic stress increases catabolism and breakdown of lean body mass

      To meet the increased demands of metabolic stress and spare the use of endogenous protein stores, a greater amount of protein is needed in this population until the underlying stress has been overcome

      Pediatric critical/surgical care population
      0 to 2 y: 2 to 3 g/kg/day

      2 to 13 y: 1.5 to 2 g/kg/day

      Adolescents: 1.5 g/kg/day
      Dietary Reference Intake (DRI)

      National Academy of Sciences, Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients) (2005).
      Replaces the 1989 RDA

      Protein needs were determined from children with normal growth, body composition, and activity, and who are also metabolically normal

      Children with normal growth, body composition, and activity, and who are also metabolically normal
      0 to 6 mo: 1.52 g/kg/day

      (This is an Adequate Intake recommendation, not enough research has been conducted to establish an RDA for this age group.)

      6 to 12 mo: 1.2 g/kg/day

      12 to 36 mo: 1.05 g/kg/day

      4 to 13 y: 0.95 g/kg/day

      14 to 18 y: 0.85 g/kg/day

      >18 y: 0.8 g/kg/day
      1989 Recommended Dietary Allowance (RDA)

      Committee in Dietary Allowances, Food and Nutrition Board, National Research Council. Recommended Dietary Allowances.10th ed. Washington, DC: National Academies Press; 1989.
      Based on the median nutrient intakes of children followed in longitudinal growth studies

      It can overestimate needs in nonactive populations (eg, bedridden) and does not provide a range of energy needs Although an outdated reference, still widely used

      Children with normal growth, body composition, and activity, and who are also metabolically normal
      0 to 6 mo: 2.2 g/kg/day

      6 to 12 mo: 1.6 g/kg/day

      1 to 3 y: 1.2 g/kg/day

      4 to 6 y: 1.1 g/kg/day

      7 to 14 y: 1 g/kg/day

      15 to 18 y (males): 0.9 g/kg/day

      15 to 18 y (females): 0.8 g/kg/day
      Peterson's Failure to Thrive

      Peterson KE, et al. Team management of failure-to-thrive. JADA. 1984;84(7):810-815.
      This calculates nutrients in excess of the requirements of the RDA

      Concerns with using this equation include refeeding syndrome

      It can be calculated using a method similar to the one for calories above

      Infants and children who present underweight and need to achieve catch up growth
      [Protein required for weight age (g/kg/day)×ideal weight for age (kg)]÷actual weight (kg)
      a Adapted from Carney LN. Assessment of nutrition status by age and determining nutrient needs. In: Corkins MR, Balint J, Bobo E, Plogsted S, Yaworski JA, eds. The A.S.P.E.N. Pediatric Nutrition Support Core Curriculum. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition; 2010:418-419, with permission from the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).
      World Health Organization
      Energy and Protein Requirements. Report of a Joint FAO/WHO/UNU Expert Consultation.
      A.S.P.E.N. does not endorse the use of this material in any form other than its entirety.
      b DRI/IOM=Dietary Reference Intake/Institute of Medicine.
      c FAO/WHO=Food and Agricultural Organization of the United Nations/World Health Organization.
      d This reference applies to the specific ages listed. Please refer to another equation for ages outside of the referenced ages, and apply an appropriate activity/stress factor.
      e UNU=United Nations University.
      The Dietary Reference Intake for protein
      Institute of Medicine, Food and Nutrition Board
      Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids.
      is typically used to estimate protein needs for both the healthy child and the hospitalized child. However, the child’s clinical status should be considered when estimating protein requirements. Some situations may require protein intakes greater than the Dietary Reference Intake to achieve a positive nitrogen balance. Examples include major surgery, wound healing, infection, and catch-up growth. Conversely, some situations (eg, critically ill patient with acute renal failure) may warrant moderate protein restriction. A comprehensive discussion of this issue is beyond the scope of this article, but may be found elsewhere in the literature.
      • Carney L.N.
      • Blair J.
      Assessment of nutritional status and determining nutrient needs.
      • Meyer R.
      • Kulinskaya E.
      • Briassoulis G.
      • et al.
      The challenge of developing a new predictive formula to estimate energy requirements in ventilated critically ill children.
      • Kim M.H.
      • Kim J.H.
      • Kim E.K.
      Accuracy of predictive equations for resting energy expenditure (REE) in non-obese and obese Korean children and adolescents.
      • Arrowsmith F.E.
      • Allen J.R.
      • Gaskin K.J.
      • Somervilee H.
      • Birdsall J.
      Nutritional rehabilitation increases resting energy expenditure in children with cerebral palsy.
      • DeWit B.
      • Meyer R.
      • Desai A.
      • Macrae D.
      • Pathan N.
      Challenge of predicting resting energy expenditure in children undergoing surgery for congenital heart disease.
      • Hill R.J.
      • Lewindon P.J.
      • Withers G.D.
      • Ee L.C.
      • Cleghorn G.J.
      • Davies D.S.
      Ability of commonly used predictive equations to predict resting energy expenditure in children with inflammatory bowel disease.

      Growth Parameters

      Growth is the primary outcome measure of nutritional status in children.
      • Mehta N.M.
      • Corkins M.R.
      • Lyman B.
      • et al.
      Defining pediatric malnutrition: A paradigm shift towards etiology-related definitions.
      • Carney L.N.
      • Blair J.
      Assessment of nutritional status and determining nutrient needs.
      • Baer M.T.
      • Harris A.B.
      Pediatric nutrition assessment: Identifying children at risk.
      Growth should be monitored at regular intervals throughout childhood and adolescence and should also be measured every time a child presents, in any health setting, for preventive, acute, or chronic care. In children younger than 36 months of age, measures of growth include length-for-age, weight-for-age, head circumference-for-age, and weight-for-length. In children ages 2 to 20 years standing height-for-age, weight-for-age, and body mass index (BMI)-for-age are typically collected.

      National Center for Chronic Disease Prevention and Health Promotion: Nutrition & Physical Activity. Use and Interpretation of the CDC Growth Charts: An Instructional Guide. 2007. http://www.cdc.gov/nccdphp/dnpa/growthcharts/guide_intro.htm. Accessed May 5, 2014.

      • Gomez F.
      • Galvan R.R.
      • Cravioto J.
      • Frenk S.
      Malnutrition in infancy and childhood, with special reference to kwashiorkor.
      • Chavez R.
      • Frenk S.
      • Galvan R.R.
      • Gomez F.
      • Munoz J.C.
      • Vazquez J.
      Mortality in second and third degree malnutrition.
      • Seoane N.
      • Latham M.C.
      Nutritional anthropometry in the identification of malnutrition in childhood.

      Centers for Disease Control and Prevention. Growth charts. 2000 CDC growth charts for the United States. http://www.cdc.gov/growthcharts/. Accessed May 5, 2014.

      Anthropometric measures of growth are typically expressed and reported in comparison to population data. Traditionally, these measures are expressed as percentiles and express the rank or position of a child’s measurements on a standard reference curve. Percentiles indicate the portion of the reference population that lies above or below that of the child being measured. It is used to help parents understand where their child “fits” in a population of children of similar ages, heights, and/or weights. The charts are designed so that growth trends in the individual child can be observed over time, and growth problems, when detected, are addressed in a timely manner.

      National Center for Chronic Disease Prevention and Health Promotion: Nutrition & Physical Activity. Use and Interpretation of the CDC Growth Charts: An Instructional Guide. 2007. http://www.cdc.gov/nccdphp/dnpa/growthcharts/guide_intro.htm. Accessed May 5, 2014.

      However, a percentile does not reveal the actual degree of deviation from population norms. The percentile will always be positive because the bell-shaped curve, statistically, has an infinite tail on both sides.
      More recently, growth charts that facilitate comparison of units of SD from norms for reference age groups, z score (SD) comparisons, are recommended for tracking and assessing nutritional status in children.
      • Mehta N.M.
      • Corkins M.R.
      • Lyman B.
      • et al.
      Defining pediatric malnutrition: A paradigm shift towards etiology-related definitions.

      Centers for Disease Control and Prevention. Growth charts. 2000 CDC growth charts for the United States. http://www.cdc.gov/growthcharts/. Accessed May 5, 2014.

      World Health Organization
      Department of Nutrition for Health and Development. Training Course on Child Growth Assessment: WHO Child Growth Standards.
      A z score is a statistical measure that tells how a single data point compares to normal data and, if above or below “average,” how atypical the measurement is. Growth measurements that cross z score lines indicate possible risk. Children who are growing and developing normally will be on or between −1 and 1 z score of a given indicator. Interpretation of the significance of z score data is based on the point at which, in the child’s pattern of growth, the change began and the child’s health status relative to the point and progression of change.
      • Mehta N.M.
      • Corkins M.R.
      • Lyman B.
      • et al.
      Defining pediatric malnutrition: A paradigm shift towards etiology-related definitions.
      • Waterlow J.C.
      • Buzina R.
      • Keller W.
      • Lane J.M.
      • Nichaman M.Z.
      • Tanner J.M.
      The presentation and use of height and weight data for comparing the nutritional status of groups of children under the age of 10 years.
      • Dibley M.J.
      • Staehling N.W.
      • Nieburg P.
      • Trowbridge F.L.
      Interpretation of Z-score anthropometric indicators derived from the international growth reference.
      The CDC recommend that the WHO comparative data charts be used as normative standards for US children from birth to 2 years of age and that the CDC comparative data charts be used as normative standards for US children ages 2 to 20 years.

      Centers for Disease Control and Prevention. Growth charts. 2000 CDC growth charts for the United States. http://www.cdc.gov/growthcharts/. Accessed May 5, 2014.

      According to the CDC, growth charts are not intended for use as a sole diagnostic instrument, but contribute to the formation of an overall clinical impression of the child being assessed.

      Weight Gain Velocity

      Mehta and colleagues
      • Mehta N.M.
      • Corkins M.R.
      • Lyman B.
      • et al.
      Defining pediatric malnutrition: A paradigm shift towards etiology-related definitions.
      suggest that a better definition of malnutrition should include goals of early identification of children at risk for malnutrition and the development of thresholds for intervention. One criterion for the early identification of undernutrition is the assessment of growth velocity and its comparison to a standard. The A.S.P.E.N. workgroup included growth within its five domains, as part of the construct of the definition of pediatric malnutrition.
      • Mehta N.M.
      • Corkins M.R.
      • Lyman B.
      • et al.
      Defining pediatric malnutrition: A paradigm shift towards etiology-related definitions.
      Growth is defined as an increase in size and the development to maturity, and growth velocity as the rate of change in weight or length/height over time. This rate of change can be interpreted as an early sign of healthy or unhealthy response to the nutritional environment.
      • Iannotti L.L.
      • Zavaleta N.
      • Huasasquiche C.
      • Leon Z.
      • Caulfield L.E.
      Early growth velocities and weight gain plasticity improve linear growth in Peruvian infants [published online ahead of print October 1, 2012].
      Upon initial presentation, length for children under 24 months of age and height for children older than 24 months of age reflects the child’s nutritional status over a prolonged period of time. A negative z score can be used to determine pediatric malnutrition when only a single data point is available. Over time, declines in z scores for length/height can also be used as a characteristic to determine undernutrition.
      Average daily/monthly rates of weight gain that allow a child to remain stable on a growth curve occur when adequate nutrient intake takes place. These rates are determined by the trajectory of the growth curve and vary by age and period of development. During periods of growth, an average daily or monthly weight gain is required for the child to remain stable on the growth curve. Very low weight velocity as occurs with lack of weight gain and weight loss in a child, has been noted to be “independently and more closely related to mortality than other indicators of malnutrition, such as BMI for age.”
      • O’Neil S.M.
      • Fitzgerald A.
      • Briend A.
      • Van den Broeck J.
      Child mortality as predicted by nutritional status and recent weight velocity in children under two in rural Africa.
      There is a tremendous amount of plasticity in growth in the short term. This adaptive response is seen when an event such as illness or trauma occurs that results in cessation of growth. With ongoing adequate nutrient intake, the child recovers and “catch up growth” with greater than normal rates of weight gain velocity results.
      • Lampl M.
      Human growth from the cell to the organism: Saltations and integrative physiology.

      MUAC

      MUAC should be measured when assessing the nutritional status of pediatric patients.
      MUAC can be used as an independent anthropometric assessment tool in determining malnutrition in children 6 to 59 months of age when compared with the standards developed by WHO.
      • Mei Z.
      • Grummer-Strawn L.M.
      • de Onis M.
      • Yip R.
      The development of MUAC-for-age reference data recommended by a WHO expert committee.
      Although reference ranges with SDs are not available for older children and adolescents, Frisancho
      • Frisancho A.R.
      New norms of upper limb fat and muscle areas for assessment of nutrition status.
      provides percentile guidelines for ages 1 to 79 years. MUAC has been correlated to BMI in children
      • Schweizer J.
      • Gerver W.J.
      Mid-upper arm circumference is a reliable predictor of body-mass index in healthy Dutch children.
      • Martin A.C.
      • Pascoe E.M.
      • Forbes D.A.
      Monitoring nutritional status accurately and reliably in adolescents with anorexia nervosa.
      and adults
      • Powell-Tuck J.
      • Hennessy E.M.
      A comparison of mid upper arm circumference, body mass index and weight loss as indices of undernutrition in acutely hospitalized patients.
      and has shown to be more sensitive to changes in muscle and fat mass than BMI in adults.
      • Powell-Tuck J.
      • Hennessy E.M.
      A comparison of mid upper arm circumference, body mass index and weight loss as indices of undernutrition in acutely hospitalized patients.
      MUAC measurements should be part of the full anthropometric assessment in all patients, and are particularly important in those whose weight may be affected by lower-extremity edema, ascites, or steroids, as weight trends alone are unreliable related to fluid status. When serial z scores are unavailable, serial MUAC measurements can be used to monitor changes in body composition using the child as his or her own control. MUAC has been indicated as a more sensitive prognostic indicator for mortality than weight-for-height parameters in malnourished pediatric patients.
      • Briend A.
      • Marie B.
      • Fontaine O.
      • Garenne M.
      Mid-upper arm circumference and weight-for-height to identify high-risk malnourished under-five children.
      • Rasmussen J.
      • Andersen A.
      • Fisker A.B.
      • et al.
      Mid-upper-arm-circumference and mid-upper-arm circumference z-score: The best predictor of mortality?.
      It is advisable to have trained individuals consistently perform these measurements for best long-term comparison of data.

      Handgrip Strength

      Handgrip strength is a simple, noninvasive measurement commonly used to measure baseline functional status and track progress throughout the course of therapy. Using a handheld dynamometer, subjects perform a series of standardized movements that measure the maximum isometric strength of the hand and forearm muscles. The dynamometer is a simple, noninvasive, and low-cost instrument to measure functional status.
      In the hospitalized setting, handgrip strength has been shown to predict postoperative complications, length of hospital admission, readmission, likelihood of returning to previous home setting, and mortality.
      • Webb A.R.
      • Newman L.A.
      • Taylor M.
      • Keogh J.B.
      Hand grip dynamometry as a predictor of postoperative complications. Reappraisal using age standardized grip strengths.
      Because muscle function reacts earlier to changes in nutritional status than muscle mass, handgrip strength may be a more acute measurement of response to nutrition interventions than traditional biochemical or anthropometric measurements in children ages 6 years and older. In hospitalized pediatric patients, handgrip strength has been used as a simple noninvasive test of functional capacity at admission for surgery. BMI z scores correlated with the admission handgrip strength measurement, regardless of sex, age, disease severity, or anthropometric characteristics.
      • Secker D.J.
      • Jeejeebhoy K.N.
      Subjective global assessment for children.
      Accurate handgrip measurements require procedure standardization. Equipment calibration, adequate staff training (patient positioning/dynamometer setting), and use of the appropriate reference range (device dependent) are important components in ensuring accurate results.
      • Webb A.R.
      • Newman L.A.
      • Taylor M.
      • Keogh J.B.
      Hand grip dynamometry as a predictor of postoperative complications. Reappraisal using age standardized grip strengths.
      • Secker D.J.
      • Jeejeebhoy K.N.
      Subjective global assessment for children.
      • Hebert L.J.
      • Maltais D.B.
      • Lepage C.
      • Saulnier J.
      • Crete M.
      • Perron M.
      Isometric muscle strength in youth assessed by hand-held dynamometry: A feasibility, reliability, and validity study.
      Appropriate age- and sex-specific reference ranges must be used. In pediatric populations, hand-held dynamometry has been proven feasible and reliable across a wide age range (6 years and older) and multiple diagnoses; however, normal reference ranges in large populations have not been established. Mild, moderate, and severe deficit ranges as measured by handgrip strength have not been established, therefore, handgrip strength can help to identify the presence of malnutrition but not to quantify the degree of the deficit.

      Proxy Measures as Substitutes for Traditional Anthropometric Measures

      In selected diseases or conditions, physical anomalies or patient frailty may limit the clinician’s ability to obtain the typical anthropometric measurements used to assess growth. A number of alternative measurements have been used in such instances to estimate weight and length.
      • Carney L.N.
      • Blair J.
      Assessment of nutritional status and determining nutrient needs.
      Please refer to Table 1 for examples of such proxy measures and review relevant literature to determine which measures offer the greatest accuracy in the clinical context in which the patient presents.

      Documentation of Tanner Stage

      There is a well-recognized association between normal pubertal development and nutritional status; however, determinants of the age of onset of puberty are multifactorial. Although Tanner stage cannot be used as a marker of nutritional status in prepubescent children, it might be useful as an indirect indicator in preteens and adolescents who have entered puberty, when Tanner progression or stagnation may be influenced by nutritional status.
      The onset of puberty varies from individual to individual, with a range of about 5 years.
      • Bourguignon J.P.
      • Juul A.
      Normal female puberty in a developmental perspective.
      Basic inherited genetic determinants interact with environmental influences to trigger the onset of puberty.
      • Bourguignon J.P.
      • Juul A.
      Normal female puberty in a developmental perspective.
      Pubertal development is classically staged by a set of physical parameters described by Marshall and Tanner.
      • Marshall W.A.
      • Tanner J.M.
      Variations in pattern of pubertal changes in girls.
      • Marshall W.A.
      • Tanner J.M.
      Variation in the pattern of pubertal changes in boys.
      Reports from developing countries indicate that girls with lower weight and height are at lower Tanner stages than their peers of the same age.
      • Gupta N.
      • Singh M.P.
      • Dhillon B.S.
      • Saxena N.C.
      Preparing for adulthood—Patterns of physical growth, sexual maturity and menarche of adolescent girls in selected urban slums and urban areas.
      • Garnier D.
      • Simondon K.B.
      • Bénéfice E.
      Longitudinal estimates of puberty timing in Sengalese adolescent girls.
      US data from the last National Health and Nutrition Examination Survey III (1988–1994) found a significant discordance for Tanner staging between the physical parameters for boys and girls if the weight and BMI were above or below the mean of children in their same age group.
      • Schubert C.M.
      • Chumlea W.C.
      • Kulin H.E.
      • Lee P.A.
      • Himes J.H.
      • Sun S.S.
      Concordant and discordant sexual maturation among US children in relation to body weight and BMI.
      The use of Tanner staging as a nutrition marker is limited by the significant degree of variability in genetic determinants for the onset of puberty from one child to another. There is also the currently unknown correlation of how pubertal development could be altered to a greater or lesser extent depending on the degree of malnutrition. This is certainly a fertile area for additional research.

      Classifying Pediatric Malnutrition

      Historically, pediatric malnutrition related to undernutrition has been classified as a percentage of ideal body weight. This type of distribution of percentages of ideal body weight was first described by Gomez and colleagues,
      • Gomez F.
      • Galvan R.R.
      • Cravioto J.
      • Frenk S.
      Malnutrition in infancy and childhood, with special reference to kwashiorkor.
      who demonstrated a correlation between the severity of undernutrition and death. The Gomez Classification
      • Gomez F.
      • Galvan R.R.
      • Cravioto J.
      • Frenk S.
      Malnutrition in infancy and childhood, with special reference to kwashiorkor.
      and the Waterlow Criteria
      • Waterlow J.C.
      Classification and definition of protein-calorie malnutrition.
      use this standard and define mild, moderate, and severe malnutrition as 76% to 90%, 61% to 75%, <60%,
      • Gomez F.
      • Galvan R.R.
      • Cravioto J.
      • Frenk S.
      Malnutrition in infancy and childhood, with special reference to kwashiorkor.
      and 80% to 89%, 70% to 79%, and <70%,
      • Waterlow J.C.
      Classification and definition of protein-calorie malnutrition.
      respectively.
      In the past, the definitions of undernutrition and failure to thrive included decreases in two centile channels or faltering growth as weight gain below the fifth percentile.
      • Waterlow J.C.
      Classification and definition of protein-calorie malnutrition.
      • Edmond A.M.
      • Blair P.S.
      • Emmett P.M.
      • Drewett R.F.
      Weight faltering in infancy and IQ at age 8 years in Avon Longitudinal Study of Parents and Children.
      • O’Brien L.M.
      • Heycock E.G.
      • Hanna M.
      • Jones P.W.
      • Cox J.L.
      Postnatal depression and faltering of growth: A community study.
      A deceleration of weight in time has also been used to define malnutrition.
      • Eskedal L.T.
      • Hagemo P.S.
      • Seem E.
      • Eskild A.
      • Cvancarova M.
      • Seiler S.
      Impaired weight gain predicts risk of death after surgery for congenital heart defects.
      The use of z score, decline in z score, and negative z score to identify and document pediatric malnutrition/undernutrition is now recommended.
      Classification of undernutrition using MUAC measures was suggested in children between the ages of 6 and 60 months. Children who are severely malnourished are defined as those with measurements <11.5 cm, moderately malnourished is those with measurements between 11.5 and 12.4 cm, and those at risk of malnutrition are those with measurements between 12.5 and 13.4 cm.
      • Olsen E.M.
      • Peterson J.
      • Skovgaard A.M.
      • Welle B.
      • Jorgensen T.
      • Wright C.M.
      Failure to thrive: The prevalence and concurrence of anthropometric criteria in a general infant population.
      An analysis by the WHO and UNICEF showed that children with a weight for height with z scores less than −3 SD were at a ninefold greater risk of death then were children with a z score of −1 SD.
      • Mehta N.M.
      • Corkins M.R.
      • Lyman B.
      • et al.
      Defining pediatric malnutrition: A paradigm shift towards etiology-related definitions.
      Similar studies using MUAC as a diagnostic criteria showed that risk of dying increased with measures of 11.5 cm.
      • Mogeni P.
      • Twahir H.
      • Bandika V.
      • et al.
      Diagnostic performance of visible severe wasting for identifying severe acute malnutrition in children admitted to hospital in Kenya.
      • Myatt M.
      • Khara T.
      • Collins S.
      A review of methods to detect cases of severely malnourished children in the community based therapeutic care programs.
      • Duggan M.B.
      Anthropometry as a tool for measuring malnutrition: Impact of the new WHO growth standards and references.
      • Black R.E.
      • Allen L.H.
      • Bhutta Z.A.
      • et al.
      Maternal and child undernutrition: Global and regional exposure and health consequences.
      • Secker D.J.
      • Jeejeebhoy K.H.
      How to perform subjective global nutritional assessment in children.
      Mild malnutrition related to undernutrition is usually the result of an acute event, either due to economic circumstances or acute illness and presents with unintentional weight loss or weight gain velocity less than expected.
      Moderate malnutrition related to undernutrition occurs due to undernutrition of significant duration that results in weight for length/height values or BMI for age values that are below the normal range.
      Severe malnutrition related to undernutrition occurs as a result of prolonged undernutrition and is most frequently quantified by declines in rates of linear growth that result in stunting.
      On initial presentation, a child may have only a single data point for use as a criterion for the identification and diagnosis of malnutrition related to undernutrition. When this is the case, the use of z scores for weight for height/length, BMI for age, length/height for age or MUAC criteria as stated in Table 2 is indicated.
      Table 2Primary indicators when only a single data point is available for use as a criterion for identification and diagnosis of malnutrition related to undernutrition: Academy of Nutrition and Dietetics/American Society of Parenteral and Enteral Nutrition 2014 Pediatric Malnutrition Consensus Statement
      • Olsen E.M.
      • Peterson J.
      • Skovgaard A.M.
      • Welle B.
      • Jorgensen T.
      • Wright C.M.
      Failure to thrive: The prevalence and concurrence of anthropometric criteria in a general infant population.
      • Mogeni P.
      • Twahir H.
      • Bandika V.
      • et al.
      Diagnostic performance of visible severe wasting for identifying severe acute malnutrition in children admitted to hospital in Kenya.
      • Myatt M.
      • Khara T.
      • Collins S.
      A review of methods to detect cases of severely malnourished children in the community based therapeutic care programs.
      • Black R.E.
      • Allen L.H.
      • Bhutta Z.A.
      • et al.
      Maternal and child undernutrition: Global and regional exposure and health consequences.
      • Secker D.J.
      • Jeejeebhoy K.H.
      How to perform subjective global nutritional assessment in children.
      Primary indicatorsMild malnutritionModerate malnutritionSevere malnutrition
      Weight for height z score−1 to −1.9 z score−2 to −2.9 z score−3 or greater z score
      BMI
      BMI=body mass index.
      for age z score
      −1 to −1.9 z score−2 to −2.9 z score−3 or greater z score
      Length/height z scoreNo dataNo data−3 z score
      Mid-upper arm circumferenceGreater than or equal to −1 to −1.9 z scoreGreater than or equal to −2 to −2.9 z scoreGreater than or equal to −3 z score
      a BMI=body mass index.
      When a child presents with historical medical information and two or more data points are available for use as criteria for the identification and diagnosis of malnutrition related to undernutrition, the criteria in Table 3 might also be used to support malnutrition’s (undernutrition) identification and diagnosis. The 1982 Foman data are still being used as growth velocity standards, but we recommend using the WHO data for patients <2 years of age.
      • Fomon S.J.
      • Haschke F.
      • et al.
      Body composition of reference children from birth to age 10 years.
      Table 3Primary indicators when two or more data points are available for use as criteria for identification and diagnosis of malnutrition related to undernutrition: Academy of Nutrition and Dietetics/American Society of Parenteral and Enteral Nutrition 2014 Pediatric Malnutrition Consensus Statement
      • Olsen E.M.
      • Peterson J.
      • Skovgaard A.M.
      • Welle B.
      • Jorgensen T.
      • Wright C.M.
      Failure to thrive: The prevalence and concurrence of anthropometric criteria in a general infant population.
      • Mogeni P.
      • Twahir H.
      • Bandika V.
      • et al.
      Diagnostic performance of visible severe wasting for identifying severe acute malnutrition in children admitted to hospital in Kenya.
      • Myatt M.
      • Khara T.
      • Collins S.
      A review of methods to detect cases of severely malnourished children in the community based therapeutic care programs.
      • Black R.E.
      • Allen L.H.
      • Bhutta Z.A.
      • et al.
      Maternal and child undernutrition: Global and regional exposure and health consequences.
      • Secker D.J.
      • Jeejeebhoy K.H.
      How to perform subjective global nutritional assessment in children.
      Primary indicatorsMild malnutritionModerate malnutritionSevere malnutrition
      Weight gain velocity (<2 y of age)<75%
      From Guo et al.84
      of the norm
      World Health Organization data for patients younger than 2 y old.85
      for expected weight gain
      <50%
      From Guo et al.84
      of the norm
      World Health Organization data for patients younger than 2 y old.85
      for expected weight gain
      <25%
      From Guo et al.84
      of the norm
      World Health Organization data for patients younger than 2 y old.85
      for expected weight gain
      Weight loss (2 to 20 y of age)5% usual body weight7.5% usual body weight10% usual body weight
      Deceleration in weight for length/height z scoreDecline of 1 z scoreDecline of 2 z scoreDecline of 3 z score
      Inadequate nutrient intake51% to 75% estimated energy/protein need26% to 50% estimated energy/protein need≤25% estimated energy/protein need
      a From Guo et al.
      • Guo S.
      • Roche A.F.
      • Foman S.J.
      • et al.
      Reference data on gains in weight and length during the first two years of life.
      b World Health Organization data for patients younger than 2 y old.

      World Health Organization. Child growth standards. Weight velocity. http://www.who.int/childgrowth/standards/w_velocity/en/index.html. Accessed September 4, 2014.

      Nutrition Surveillance and Continuity of Care

      Once the diagnosis of pediatric undernutrition is made, it is crucial to determine how often nutritional status should be monitored and what processes will be established to ensure continuity of care between settings. These questions require answers that ensure improved outcomes for the child with this diagnosis.
      One of the mandates of the Affordable Care Act and “meaningful use” is to facilitate care transition across the health care system.

      The Patient Protection and Affordable Care Act (PPACA), Pub. L. No. 111-148, 124 Stat. 119, 2010. Mar 23.

      The Centers for Medicare and Medicaid Services will require monitoring and re-evaluation of patients’ health conditions and that continuation of care is planned, executed, and documented (see www.HealthIT.gov). A specific timeframe for these requirements has yet to be delineated. Providing nutrition surveillance will undoubtedly improve outcomes and reduce hospital readmission rates. The nutrition care process
      Pediatric Nutrition Dietetic Practice Group
      provides guidelines for monitoring and evaluation of nutrition therapy provided. The ideal frequency for nutrition surveillance, however, remains elusive.
      It will be difficult to standardize follow-up surveillance intervals because of the great variation in severity of growth failure, nutritional habits, and in coexisting morbidities, chronic disease(s), social situations, etc.
      • Gupta K.
      • Nobel A.
      • Kachelries K.
      • et al.
      A novel enteral nutrition protocol for the treatment of pediatric Crohn’s disease.
      • Skog A.
      • Eliasson H.
      • Tingstrom J.
      • et al.
      The Swedish Congenital Heart Block Study Group
      Long-term growth of children with autoantibody mediated congenital heart block.
      • Ali E.
      • Zachariah R.
      • Shams Z.
      • et al.
      Is mid-upper arm circumference alone sufficient for deciding admission to a nutritional programme for childhood severe acute malnutrition in Bangladesh?.
      • Heushckel R.
      • Salvestrini C.
      • Beattie R.M.
      • Hildebrand H.
      • Walters T.
      • Griffiths A.
      Guidelines for the management of growth failure in childhood inflammatory bowel disease.
      Optimally, follow-up intervals for pediatric malnutrition (undernutrition), like any other medical condition, should be individualized.

      Call to Action: Next Steps

      This consensus statement represents a starting point in the effort to standardize a diagnostic approach to the identification and documentation of pediatric undernutrition. It is important that all clinicians caring for pediatric patients use the recommended diagnostic indicators to identify and document nutritional status in children and adolescents. It is also imperative that clinicians make every effort to obtain and enter numerical data into searchable fields in the electronic medical record, in order to make tracking within and among institutions feasible.
      Members of the health care team should come together to determine strategies for implementation compatible with their own institution’s policies and practices. Standardized formats for the collection of data associated with each indicator’s use are needed in order to validate and determine which characteristics are the most or least reliable in the identification of pediatric undernutrition and its treatment. Uniform data collection across facilities at local, regional, and national levels would facilitate feasibility testing on a broad scale. The indicators recommended in this consensus statement should be reviewed and revised at regular intervals to reflect validation data that offers evidence of efficacy.
      We also need to begin to develop systems that track the diseases or conditions, and environmental or socioeconomic circumstances that contribute to, or that are routinely associated with, the development of pediatric undernutrition. The human and financial impact of the routine use of the recommended indicators in such areas as resource utilization, revenue generation, and personnel needed to adequately address the needs of undernourished children and adolescents in acute, ambulatory, home, and residential care settings should also be tracked.
      The education and training needs of nutrition, medical, and allied health professionals should be determined, with appropriate outreach initiated to remediate identified deficits. Additional training in the nutrition assessment protocol is recommended and in the development and utilization of electronic systems that facilitate data collection in this highly vulnerable and costly segment of our population should be offered in multiple venues as specific identified needs arise.

      Summary

      The recommended indicators to diagnose pediatric undernutrition delineated in this consensus statement are a work in progress. Clinicians should expect to see an evolution of these recommendations as data regarding their use are systematically collected, analyzed, and disseminated to research and clinical communities. Periodic review and revision of our recommendations will ensure that the health of the public is optimized and that utilization of health care resources proceeds with maximum efficiency.

      Acknowledgements

      The authors thank staff at the Academy of Nutrition and Dietetics: Mara Bujnowski, MAEd, RD, and Marsha Schofield, MS, RD, LD, FAND; the American Academy of Pediatrics: Debra L. Burrowes, MHA; and the American Society for Parenteral and Enteral Nutrition Clinical Practice Committee, Malnutrition Committee, Board of Directors, and staff member Peggi Guenter, PhD, RN, for their unfailing patience and support and for their many constructive comments and suggestions.

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      Biography

      P. J. Becker is a pediatric dietitian II, Cincinnati Children's Hospital Medical Center, Cincinnati OH; at the time of the study, she was a clinical nutrition manager, Outpatient Services, University of North Carolina Health Care, Chapel Hill, NC.
      L. Nieman Carney is a clinical dietitian IV, The Children's Hospital of Philadelphia, Philadelphia, PA.
      E. Smith is a clinical dietitian IV, The Children's Hospital of Philadelphia, Philadelphia, PA.
      M. R. Corkins is division chief of pediatric gastroenterology, Le Bonheur Children’s Hospital and professor of pediatrics, University of Tennessee Health Science Center, Memphis.
      J. Monczka is a clinical dietitian specialist, Orlando Health, Orlando, FL.
      S. E. Smith is a registered dietitian, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
      B. A. Spear is a professor of pediatrics, University of Alabama at Birmingham, and director, MCH Nutrition Training Program and director, Leadership Education in Adolescent Health (LEAH), Birmingham, AL.
      J. V. White is an emeritus professor, Department of Family Medicine, Graduate School of Medicine, University of Tennessee, Knoxville.

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      • Addendum
        Journal of the Academy of Nutrition and DieteticsVol. 115Issue 5
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          The following information should be added to “Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Indicators Recommended for the Identification and Documentation of Pediatric Malnutrition (Undernutrition),” which was published in the December 2014 issue of the Journal (pp 1988-2000): This document was endorsed by the American Academy of Pediatrics.
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